Are U.S. residency training programs
producing internal medicine
physicians that are able to keep up
with modern health care needs?
THE APPROPRIATE USE OF
CONSULTATIONS
Esteban Peña
TEACHING
ATTENDINGS
“Who we are is what they become”
CASE 1
• 37 yo WF with significant history of chronic ETOH
intake admitted for acute alcoholic hepatitis.
Treated with Trental and she improved her LFTs.
• Unfortunately, the patient developed difficulty
ambulating. Symmetric, bilateral LE weakness
predominantly distal, with patellar and ankle
areflexia. No sensory level and DRE showed an
intact sphincter tone.
What is the best step in the
management of this patient?
BUT…. ROAD BLOCK
Impact of an early Neurology
consultation for IM residents.
• Do residents understand how to diagnose
symmetric bilateral lower extremity weakness?
• What is the most cost-beneficial test to promptly
achieve a diagnosis?
• Do they feel encouraged to read on medical
literature to achieve the diagnosis as soon as
possible?
• Does it delay patient care?
• Is all the testing recommended by Neurology
required “right off the bat”?
“Referrology”- the approach to
promptly diagnose a patient?
Pleural effusion= Pulmonary consult
Pancytopenia= Hematology consult
Bilateral lower extremity weakness= Neurology consult.
Chest pain= Cardiology consult.
Troponin elevation= Cardiology consult
Abnormal LFTs= GI consult.
Bacteremia= ID consult.
Death row= Palliative care.
ARE WE TEACHING RESIDENTS AND STUDENTS TO REFER
PATIENTS TO PROVIDE A DIAGNOSIS?
• IS THE IM SERVICE BECOMING A SPECIALTY THAT ONLY
DEALS WITH SOCIAL ISSUES?
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Case #2
• 27 yo WM. No significant history. ED physician
requests admission for excruciating chest pain and
“hyperdynamic t waves” on EKG to rule out ACS.
Cardiology said: “ADMIT TO MEDICINE”
• When interviewed patient states pain started
immediately after ingesting coke and candy
(Mentos®)
Coke and Mentos
“ THE GLORIFIED H&P PROVIDER”
ACP INTERNIST
“I will not be ashamed to say ‘I know not,’ nor will I fail
to call in my colleagues when the skills of another are
needed for a patient’s recovery”—the reality of our
referral patterns in today’s health care system has
gone to the opposite extreme and can be equally
dangerous. Joseph W. Stubbs, FACP
US physicians are twice likely to
refer patients to a specialist
Internal Medicine training in Europe
and other countries takes 5 years.
• Training in the U.S needs to be extremely efficient to
achieve the same goals in 3 years, or
• The result is to produce less effective internists.
• IS THIS THE CAUSE OF THE INCREASING REFERRAL
PATTERN IN THE INTERNIST TODAY?
• DOES THIS BEHAVIOR THREATENS THE PRACTICE OF
INTERNAL MEDICINE?
Hospital Statistics
• Intensity of care has increased in 47% 1997-2006.
• Hospital ownership: Government 14%, Non-profit
73%, For profit 13%
• 86% Community Hospitals- not all specialties are
available.
• ALOS in the country is 4.6 days and remains the
same since the year 2000.
• Common diagnosis are common- should the
internist be well prepared to deal with them with
low need of consultation?
LOS
Lets look at some data…
• C. B Forrest: “High use of specialists physicians and
specialized procedures coupled with low exposure
to primary care are distinguishing traits of the US
health care system.”
• Physicians and consulting physicians disagreed on
both the reason for consultation and the principal
clinical issue in 14% of consultations studied.
• Both primary and specialty care physicians thought
that many referrals were potentially avoidable but
failed to agree on 34% of the cases. for outpatient
referrals.
Communication…
• Purpose of the referral was explicit in only 76% of cases.
The referring physicians fared even worse: consultants
communicated their findings to the referring physicians
in only 55% of the consultations. McPhee SJ, Lo B, Saika GY,
Meltzer R. How good is communication between primary care physicians and
subspecialty consultants? Arch Intern Med. 1984;144(6) 1265-1268.
• 32% of specialists received consultative information from
the referring PCP, while 75% of referring physicians
received communication back from the specialist. Gandhi
TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication
breakdown in the outpatient referral process. J Gen Intern Med. 2000;15(9):626-631.
Specialist surveyopinions
• 60% of referrals were for conditions that should be
easily manageable by general practitioners with
access to the right information (dermatology,
cardiology &orthopedics). Guidelines partly explain
differences in referral rates BMJ. 2002 November 16;
325(7373): 1177.
• Interventional study: 28% Improved unnecessary
referral in CKD 3 patients to Nephrology (Spain)
Specialist vs. PCP
• Specialists are more likely to provide evidence based
medicine.
• Co- management improves outcomes.
• 50% of consultations are “self referrals”. Mostly related to
patient dissatisfaction.
• 19% repeated referral (poor communication or
inadequate knowledge)
• Intervention study: 1 out of 10 patients when screened
truly required a face to face visit with a specialist.
• 52% of referrals bypassed the PCP to another specialist.
• Asthma study: worse outcomes from an internist than
from an asthma specialist. RCT 3 years.
Appropriateness of
referrals
• Only 16 articles
published.
• 0.7- 65% pediatric
orthopedics
• Under referral 19%
stage III and IV
colorectal Ca for
adjuvant therapy.
• 87% retinopathy
screening in DM and
HTN
• Adherence to existing
guidelines.
• Judgment by the
provider
• Does it change the
diagnosis or
management
• Procedure required
What are the consequence
of inadequate referral ?
Under referral:
• Delayed diagnosis.
• Delayed treatment.
• Increased risk of
malpractice suits (5%).
• Increased morbidity
and mortality (CKD)
Over referral:
• Reduced continuity of
care.
• Polypharmacy.
• Increased risk of
malpractice suits.
“CYA” (20% poor
communication and
unclear lines of
responsibility with
specialist)
• Increases cost
Referral decisions is heterogeneous
amongst internists
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Presenting problem
Patient’s expectation
Certainty of diagnosis
Type of training (specialist will likely refer for issues not
related to his specialty)
Number of years of experience- the more years in
practice the more referrals or extremely young
physician.
Concerns about malpractice
Practice environment.
Prior interaction with specialists
Female physicians
Similar pattern in
pediatric population
• Routine care provided by specialists to children and
adolescents in the United States (2002-2006). BMC
Health Services Research 2009, 9:221
What is the most probable
future of IM in acute care?
• Slowly disappears as ER doctors can recognize and
place referral for any abnormality. Social issues can
be dealt by a more efficient system. Do we really
need two doctors to triage and consult?
• The cost-effectiveness of referrals is too expensive.
IM service admits the great majority of the
population (chest pain, CHF, etc.). Are residents
prepared for this possibility?
WHAT IS A
HOSPITALIST?
• Internal Medicine Physician- provides acute care to
hospitalized patient in the area or internal
medicine.
• The branch of medicine that deals with the
diagnosis and (nonsurgical) treatment of diseases
of the internal organs (especially in adults).
Hospitalist
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Diagnostician.
Acute care/ Internal Medicine.
Prevention and treatment of disease.
Specialty referral- inpatient or outpatient.
Cost for patient, insurance companies and hospital.
Quality improvement.
How Hospitals get paid?
• Case-based payments (D.R.G.’s)
• Set amount of dollars per day of inpatient stay (perdiem payments)
• Fees for individual services and supplies (fee-forservice or F.F.S. payments).
• The levels of these payments are set unilaterally by
the state governments. In many states these
payments are much lower than the full cost of
providing the services.
Length of Stay
• Patients who stay for a shorter period of time generate
more money for the hospital.
• Hospitals are often anxious to get the patient stable and
discharged quickly.
• Insurance companies offer rewards for the hospitals who
have shorter stay times for their patients.
• Guidelines are closely followed that determine the
length of time a patient with a specific diagnosis can
remain in the hospital.
• Doctors who insist on longer stays are many times denied
Does over referring a patient
increase length of stay?
• The studies available are only for the OUTPATIENT
setting.
Only one study
• Infectious disease consultation: Impact on
outcomes for hospitalized patients and results of a
preliminary study. Classen MD
• 496 (intervention) vs. 3117 (control)
• Control:
Longer LOS
Longer ICU
Higher antibiotic cost.
HOW TO BE PART OF
THE SOLUTION?
• Believe that there is a problem.
• Internists performance should be measured and
compared.
• Guidelines and training.
• If patients are almost always referred- should there
be an internist in the care of the patient?
Efficiency?
• “Efficiency in general describes the extent to which
time, effort or cost is well used for the intended task
or purpose.” (Dictionary)
• Physician’s productivity (ACP):
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Number of patients per hour
Ability to bring profit to the facility and reduce cost.
Reduce fatigue and increase job satisfaction.
Improve quality of healthcare (patients and society)
HOW TO EVALUATE
HOSPITALISTS EFFICIENCY?
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Length of stay
Readmissions
Avoidable days
Participation in quality improvement meetings
Mortality
Patient/Peer surveys
Evidence based guideline.
• Report efficiency evaluations as a group and
individually to attending physicians every 6 or 12
months.
• Publish this data to encourage change in other
academic programs and be able to compare
performance.
• Targeted training for attending physicians
according to their efficiency evaluation result.
• Systematic or algorithmic approach to main
problem to approach diagnosis efficiently.
• Create guidelines that include indications for
referring a patient.
BIBLIOGRAPHY
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Improving the Primary Care–Specialty Care Interface, ARCH
INTERN MED/VOL 169 (NO. 11), JUNE 8, 2009
Arch Intern Med. 2012 January 23; 172(2): 163–170. Trends in
Physician Referrals in the US, 1999–2009
Comparison of specialty referral rates in the United Kingdom and
the United States: retrospective cohort analysis. BMJ 2002;325:370
Guidelines partly explain differences in referral rates BMJ. 2002
November 16; 325(7373): 1177.
Mehrotra, Dropping the Baton: Specialty Referrals in the United
States, The Milbank Quarterly, Vol 89 N1 2011
. Lee T, Pappius EM, Goldman L. Impact of inter-physician
communication on the effectiveness of medical consultations.
Am J Med. 1983;74(1):106-112.
McPhee SJ, Lo B, Saika GY, Meltzer R. How good is
communication between primary care physicians and
subspecialty consultants? Arch Intern Med. 1984;144(6) 1265-1268.
• Reasons for Choice of Referral Physician Among Primary Care
and Specialist Physicians, J Gen Intern Med. 2012 May; 27(5):
506–512.
• HCAP Facts and Figures, Statistics on Hospital Based Care in
the United States, 2012.
• Data Bulletin, Results from HSC Research, N35, September 2009
• Rosenblatt, Culture and Medicine: Physicians and rural
America. West J Med, 2000.
• US Department of Health and Human Services, CDC, National
Center for Health Statistics, GENERALISTS AND SPECIALTY
PHYSICIANS: SUPPLY AND ACCESS 2009-2010.
• Is general practice effective?, Support Summary of a sytemic
review, May 2011.
• Barnett, Trends in Physician Referrals in the United States 19992009. Arch Intern Med 2012;172(2)
• Garcia, Results of a coordination and shared clinical
information program between primary care and
nephrology, Nephrologia 2011 31(1)
• Forrest, A typology of specialists’ clinical roles, Arch of
Internal Medicine 2009 169(11)
• Baker, Quality of care in patients with asthma and rhinitis
treated by respiratory specialists and primary care
physicians: 3 year randomized and prospective follow up
study, Annals of Allergy and asthma & Immunology 2006
97(4)
• Franks, Why do physicians vary so widely in their referral
rates?, Journal of General Int Med 2000 15(3)